When Roy Haines first saw the coroner's findings into his son's death, he felt confused.
Aboriginal and Torres Strait Islander readers are advised that this article contains the image and name of a person who has died.
"It didn't feel real good after we read the last bit about the natural causes," Mr Haines said.
Contrary to the findings handed down in March, Mr Haines said he believed "it wasn't natural causes that he passed away, it was caused by the inappropriate health care that was given to him".
William Haines, 37, died on the floor of a Cessnock jail cell on April 27, 2021, a month after he spent time in the Cessnock, Maitland and John Hunter hospitals before being discharged with "atypical chest pain".
Vascular and general surgeon Associate Professor Anthony Grabs, an expert witness at the inquest into William's death, told the coroner he believed it was a "throwaway" diagnosis.
Deputy Coroner Carmel Forbes found there were "shortcomings" in the medical care Mr Haines received and that his death could have been prevented, but that he died of natural causes.
"I am satisfied on balance that he had a PE [pulmonary embolism] whilst in hospital, and this was not diagnosed," she said in her findings.
"If it had been, the treatment would have in all probability prevented his untimely death."
She concluded William Haines died when an undiagnosed blood clot in his left leg, specifically a deep vein thrombosis (DVT), caused a pulmonary thromboembolism (PE), which is when a clot travels and blocks blood supply to the lungs.
Magistrate Forbes noted William had a history of DVT in the years before his death, but that medical history was not transferred by the prison to the hospitals.
But family member Wendy Craigie said she believed the 'natural causes' category did not adequately reflect how William died.
"If he was treated [for DVT], he would have been alive today," she said.
In response to questions from the ABC, the NSW Coroner's Court explained the categorisation.
"Natural cause deaths are caused by illness/disease, whilst external causes are an accident, suicide or violence," the statement said.
"Mr Haines' death from pulmonary embolus falls into the natural cause category."
In response to the coroner's findings the Hunter New England Local Health District apologised to Mr Haines' family and said it did not provide him with the standard of care he deserved.
No recommendations
Roy Haines and Ms Craigie both said they felt disappointed on the day when the coroner made no recommendations following the death.
"I would've liked it to have been a lot better day, but it just turned out to be a shit day and that was it," Mr Haines said.
In her findings, Magistrate Forbes accepted that measures had already been taken to prevent similar deaths, including changes in policy requiring Justice Health to share medical alerts for prisoners with external hospitals.
But Roy Haines said he was not convinced that would work.
"Let's hope it does ... [because] we don't want other people going into hospital and being thrown out the door again," he said.
Ms Craigie said electronic medical alerts would not go far enough to ensure people from remote communities — without health records — received adequate medical care.
"People go into hospital all the time with no records from community from jail," Ms Craigie said.
The pair said now that all the inquest proceedings were finished, they were struggling to move forward.
"We're just going mad, and we just don't know what the next move is — except going to see psychs and going to talk about that," Ms Craigie said.
"But other than that, what do we do?"
Mr Haines said he would also be seeking help for his mental health.
"After, what, two years of this … it doesn't go away," he said.
